Reducing risk 
on busy days

When GPs are under time pressure, it may be easy to correct omissions such as missed referrals without stopping to consider how it happened and what can be done to prevent a similar incident in the future. Dr Rachel Birch, Medicolegal Consultant at Medical Protection, discusses this in more detail and provides practical advice on how locum GPs are well placed to help improve patient safety.

As doctors, we will all be familiar with the concept of “firefighting”— that busy day when there seems so much to do that we just put our heads down and work through it. Perhaps a couple of extra patients at the end of a surgery, or an urgent home visit in the middle, a telephone call from a consultant, or it may just be that we are running behind schedule due to a patient needing more time in their appointment.

Picture the scene— mid-morning, you review a 60 year old male patient who asks when he will hear from the hospital. Looking through his notes you can see that he attended the senior partner last week with a new onset of rectal bleeding. The red flag referral does not appear to have been done. You explain this and reassure him that you will make the referral now. The patient is happy with your plan.

No harm done? Perhaps not this time, but is it possible that there was a failure in the practice’s system, meaning that the referral was not sent? Could this situation occur again in the practice? Could there be more serious consequences if it happened to a different patient?

Perhaps you have encountered other similar incidents when working in practices. A patient who had not stopped her iron tablets for 6 months, despite now having a normal haemoglobin. A patient who has not been advised that his follow up PSA is now due.

It is easy enough to correct such incidents and think no more about it, for example by arranging a blood test, then moving on to the next patient on your list. But have you possibly missed an opportunity for learning, and has the practice missed the opportunity to improve their system and prevent the same problem from continuing to happen?

As a locum GP, you may notice these incidents more than doctors regularly working in the practice. You might also have experienced similar situations in other practices and be aware of the measures they have taken to reduce such risks.

The General Medical Council advises doctors to contribute to adverse incident recognition, reporting incidents that have the potential to put the safety of a patient at risk. They expect doctors to raise concerns if patients are at risk due to inadequate resources, policies or systems. They emphasise the importance of a patient safety culture, where staff feel able to raise concerns openly and safely.

For locum GPs, potentially working in many different practices, it is helpful to consider the best way of putting this GMC guidance into action.

The most important step is recognition of adverse incidents and also near misses— events that did not lead to harm but had the potential to do so. On a straightforward day, you may find that you can take action easily in such situations. However, on days where you are very busy, it may be more difficult to consciously say to yourself “this is a situation that I should report”, and instead you may find yourself just fixing the problem, for example, referring the patient and then moving on. Taking a couple of moments to remind yourself of this on busy days may help, as well as making a note of any issue that you want to revisit at the end of the surgery. Once you have finished your session, you will then be in a position to think more clearly about the best way to address your concern.

The next step is then to decide what is the best way to feed back the issue to the practice. If the practice uses NASGP’s Standardised Practice Information Portal (SPIP) then this may well contain easily accessible instructions on how to report incidents and refer concerns. In the absence of any locum induction pack, it would be best to speak to the practice manager or senior partner in the first instance. You may wish to outline the instance verbally, although there might be circumstances when email is easier, for practical reasons. Either way, it would be helpful to keep a record of your actions.

When outlining your concern, you should be objective and avoid apportioning blame to another clinician. Instead, it would be helpful to clarify any clinical action you have taken to address the patient’s immediate need, and let the practice know that you wanted them to be aware of the issue, so that they can take any necessary action to prevent a future recurrence. If you are a regular locum and the practice decides to discuss the matter at a future SEA meeting, ask if you can come along. With your experience of working in different practices and seeing different ways of working, you may be helpful to the practice in suggesting a possible solution.

Your annual GP appraisal would be an ideal opportunity to reflect on the instances where you have raised any concerns to practices and will also demonstrate that you have taken part in quality improvement activity. You may wish to discuss incidents in locum peer support groups, thereby also sharing the learning and getting input and advice from others.

It has often been said that every day is a learning day and that is possibly most true from busy days in General Practice. If you can get into the practice of recognising and reporting any potential patient safety risks, and incorporating this into your usual routine then, as a locum GP, you will be making an invaluable contribution to learning and patient safety, wherever you work.

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